Emergency Hospital Service Delivery - JPRM 2011 - Second Deliverable - English

Hospitals Internal Disaster Response Plan
Hospital Internal Disaster Response Plan
Momeni A., Yousefi E.
July 2011
APW for developing SOP for hospital emergency service delivery

Second Report July 2011
Amir Momeni MD. EHMTP Director Principal Investigator
Elham Yousefi MD. Technical Officer
World Health Organization & Ministry of Health and Medical Education of Islamic Republic of Iran JPRM 2010-2011
WHO/EMRO, July 2011
APW for developing SOP for hospital emergency service delivery Second Deliverable - English
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Acknowledgements:
We thank the staff of the Secretariat for Health Risk Management in Disasters of MOHME, especially Dr. Gholamreza Masoumi without whose support and cooperation this project could not have been completed. We must also stress our gratitude for members of EHMTP for their excellent field work. Last but not least we must thank the staff of WHOs Iranian office, especially Dr. Manuel Torres and Ms. Laleh Najafizadeh, whose technical insight and guidance have greatly improved the quality of this project.
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Abbreviations:
WHO World Health Organization MOHME Ministry of Health and Medical Education of Islamic Republic of Iran EHMTP Emergency Health Management Training Program CHRMS Comprehensive Hospital Risk Management System ER Emergency Room HAZMAT Hazardous Materials Team HEICS Hospital Emergency Incident Command System IC Incident Commander ICU Intensive Care Unit OR Operations Room RACE Rescue, Alert, Contain and Evacuate S&R Search & Rescue
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Introduction:
This is the second deliverable of the JPRM 2010/2011 project entitled APW for developing SOP for
hospital emergency service delivery which is being completed with collaboration of world health organization and ministry of health and medical education of Islamic Republic of Iran. In this second deliverable we
provide a framework for management of internal disasters in hospitals with emphasis on the response phase. For any inquiries regarding this project or the findings presented please contact me by email: amirmomenibr@yahoo.com
Amir Momeni MD, Project Manager June 2011
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Table of Contents
Executive Summary: ................................................................................................................................ 7 Methodology:.......................................................................................................................................... 8 1.1 Hospitals and Internal Disasters: ...................................................................................................... 11 1.2 Vulnerability of Hospitals: ............................................................................................................ 13 2.1 Protecting Lives: .............................................................................................................................. 17 2.1.1 Identifying the threats: ............................................................................................................. 17 2.1.1.2 Common Disaster Codes: ................................................................................................... 20 2.1.2 Threat Evaluation: ..................................................................................................................... 23 2.1.3 Threat Neutralization: ............................................................................................................... 32 2.1.4 Threat Containment: ................................................................................................................. 33 2.1.5 Evacuation: ............................................................................................................................... 34 2.2 Continuity of Service Delivery: ......................................................................................................... 35 2.3 Protecting the Investment: .............................................................................................................. 36 3.1 General principles of internal disaster management: ....................................................................... 37 3.1.1 Adherence to the framework set by the CHRMS: ...................................................................... 37 3.1.2 Activating the HEICS:................................................................................................................. 37 3.1.3 Activation of the response plan:................................................................................................ 38 3.1.4 Communication: ....................................................................................................................... 38 3.1.5 Resource Management: ............................................................................................................ 39 3.1.6 External Coordination: .............................................................................................................. 39 3.1.7 Public information and managing the concerned relatives: ....................................................... 39 4 References: ........................................................................................................................................ 41
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Executive Summary:
This is the second report in a series of three developed for the JPRM 2011 project APW for developing SOP for hospital emergency service delivery. In this second report a framework .
In this report an outline is provided on hospital internal disaster response plan. Internal disaster are disasters that directly affect the hospital and may be part of a disaster that has affected the society that the hospital serves as well. Hospitals are very vulnerable to internal disasters and the effects of a full blown disaster can be quite devastating. An important part of CHRMS is dedicated to internal disasters and is organized in three levels risk reduction, prevention and response. In this project we have focused on response; successful response depends on hospital disaster plans. These plans help to organize the chaotic scene following the disaster and reduce the harm and damage caused by disasters. Hospital disaster response plan should have two separate aspects; one for internal disasters and another for external disasters. In this report we have provided an outline for internal disaster response plans. In the Persian version of this report we have also provided generic plans for common internal disasters in Iran including fire emergencies, earthquakes, chemical and radiologic events, epidemics and biologic events as well as evacuation and isolation.
We have started this report with exploring the interplay of internal disasters and hospital with especial focus on the inherent characteristics of hospitals that makes them vulnerable to internal disasters. We have then provided an outline for disaster response and its objectives which are protection of lives, investment and functionality. We have then provided a framework for a hospital internal disaster response plan. At the end of the report we have introduced some general principles which are critical to the success of the hospital response actions.
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Methodology:
This is the second report in a series of three developed for the JPRM 2011 project APW for developing SOP for hospital emergency service delivery. In this first report the results of the evidence review as well as the situation analysis have been presented.
The first task for the first report was evidence review. For this a comprehensive search of all available evidence online was performed. In this search free databases including Google Scholar, Medline, WHO libraries, Indexmedicus and others were searched for practices and guidelines on hospital disaster response planning. A separate search was conducted on Google for all documented hospital disaster plans from around the world. The neighbouring countries were chosen as the benchmarks for Iran and a country specific search for hospital preparedness and response was conducted as well. The results were skimmed and all useful documents and resources were selected. The documents were categorized as policy documents, technical documents and case studies. In each category further thematic and subject based categorization was made. After documents were assigned to their categories, they were rated based on content, reliability and relevancy. Project members then thoroughly reviewed and summarized the evidence that was highly rated in the previous section and a series of meetings were held during which the topics of the project were discussed and each member contributed to the topic based on the evidence she/he had reviewed. The end result was developed in two different categories, the first was background and rationale which is presented in this report and the second category was best practices which will be used in developing the generic plans in the second and third report. The evidence that contributed to the conclusions drawn were listed as the references.
The second task was situation analysis. This was a field work for which a task force was chosen from the project members and were trained in conducting objective based interviews. A questionnaire was developed as well which assessed the basic level of preparedness in hospitals. The task force conducted interviews based on the designed questionnaire with hospital representatives and the results that were obtained were summarized and in some cases quantified. As a part of this task, the MOHME was asked to provide a report on all policies and regulations related to hospital disaster management and emergency health management as well as any experience or related project. The report was provided and evaluated; in
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evaluation all items which did not have enough supporting documentation were omitted. The end results were discussed in a series of sessions and weaknesses as well as strength of the current situation and conclusion as to what needs to be done, were determined.
The third task was developing a framework and outline upon which to proceed, it was agreed that the outline needs to address both internal and external disasters and be generic so that it can be adopted and used in hospitals around the country. Through a series of sessions the outline was developed and is presented in this report.
The results were summarized and the first report was drafted. A knowledge base was also created from all of the references.
For the second deliverable of the project, an outline of the CHRMS in internal disasters was established using focused discussion sessions of the participating members. Using the results of the first deliverable as well as the knowledge base, and by going through the best practices from around the world the framework for response to internal disasters was established. This framework is provided in the first section of the Persian version of the second report as well as the English report. An expert plan was then consulted and their inputs regarding the framework were gathered and the framework was modified accordingly.
Then based on the hazard analysis reports from previous projects and based on the inputs of the expert panel, the most common hazards faced by hospitals in Iran were chosen and to each a team was assigned. Each team developed a generic response plan based on the framework developed earlier that can be used in hospitals around Iran. As the generic plans were designed for Iranian hospitals, the plans are only in Persian and available in the second section of the Persian report.
An explanatory software, in form of a presentation that can be used both as a teaching material as well as a self-learning tool was then prepared. The findings were then summarized and an English report containing the framework for internal disaster response and a Persian report containing the framework as well as generic plans for fire emergencies, earthquakes, radiologic events, chemical events, epidemics, isolation and evacuation were written.
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1.1 Hospitals and Internal Disasters:
Hospitals are deemed as one of the most important structures of a society, in case of large medical centers their importance is considered greater than fire stations, power plants and other infrastructures within the society. Hospitals and schools, in addition to their social roles, possess a symbolic socio-political status; loss of a hospital can lead to despair, frustration and insecurity among the members of the affected society. In such instances the loss of patients lives causes a great emotional burden.
While in disasters, the society highly relies on hospitals, they themselves are highly vulnerable towards disasters. This emphasizes the need for risk reduction and risk management in hospitals. Furthermore, hospitals are the result of a considerable investment and their loss is a great financial loss. As we have stressed before the cost of repairing and rebuilding Bam hospitals following the 2004 earthquake was estimated at 10.5 million US dollars (only structural repair) and you need to add to this, the cost of repairing or replacing the damaged equipment. Yet, the financial burden is even greater, because while the hospital is inoperable, the patients need to be transferred to other hospitals within the area or temporary measures such as field hospitals should be utilized. In Bam, the cost of establishing field hospitals following the earthquake was estimated at 10 million US dollars, almost as much as the amount that was needed to rebuild the citys hospitals.
It is an undeniable fact that hospitals need protection from disasters. Such protection is provided in three levels; in internal disasters hospitals are faced with three main threats, these are threats towards the lives of the occupants, threats towards service delivery and finally threats towards the investment, this in turn implies that the three levels of protection: protecting lives, protecting investments and protecting the functionality of the hospitals.
Protecting lives is the minimum and the mandatory level of protection in every hospital; in this level all threats towards the lives of occupants (patients and staff alike) from structural, nonstructural, environmental and etc. should be averted. In order to protect investments (second level of protection), the structural and non-structural elements of the hospitals as well as the equipment should be protected from harm. In health, such protection is considered successful
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when hospital can have a fast recovery following the disaster and return to its pre-disaster status. The last level of protection (protecting the functionality) is the ultimate level of protection and it ensures while in a disaster, the occupants were safe and there was minimal damage to investment, the hospital will also be able to function during and immediately after the disaster, i.e. provide services to the patients. However in different settings hospitals may arrange their priorities differently.
The issue of prioritization between different levels of protection is very important. No matter what threat the hospital is facing, protecting lives should always be considered the number one priority. However the problem is choosing between protecting functionality and protecting investments because these levels both require a lot of man power, energy and preparation and furthermore they are sometimes contradictory; for example in order to protect the equipment a shutdown may be required, but service delivery requires the equipment to remain functional even if this damages the equipment. To solve this issue, we must look at this from a different perspective. The second priority in each hospital, after protecting lives, should be continuity of care. Priority should be given to the level of protection that is more effective in continuity of care. For example in instances where nearby hospitals can provide imaging services to patients (and transport is not an issue), then the hospitals imaging services can be stopped to allow maintenance and repair of the equipment, in other words because the nearby hospital ensures continuity of care, then in the disaster stricken hospital precedence can be given to protecting investment over protecting functionality.
Such decisions however are very difficult and controversial; usually it is not known how continuity of care can be achieved until after the disaster has occurred, so prioritizing between protecting investments or functionality is not possible beforehand. The decision, however, can be facilitated by establishing a set of guidelines and criteria in the planning and preparedness stage.
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1.2 Vulnerability of Hospitals:
Due to many complex factors, hospitals are naturally vulnerable towards internal disasters; hospitals are very large and complex structures, this would mean that in the response phase, rapid assessment, threat neutralization or containment and evacuation will be extremely difficult and time consuming. Furthermore, hospital buildings are usually older than the average age of the building within the city and as such they have many structural flows and some may lack current standard features of a resilient structure. Because of these most hospitals are structurally vulnerable towards disasters. Furthermore, structural risk reduction and retrofitting of hospitals requires a considerable financial investment which sometimes is the same amount as the investment for building a new resilient structure for the hospital. In addition to the structure itself, the installations and utilities of the hospitals also augment the vulnerability level; hospitals are highly dependent on critical installations and utilities such as electricity, heating, air conditioning, medical gases and etc. while in most hospitals some redundancy mechanisms are considered for these installations, there is always a risk that one of these essential installations and utilities becomes unavailable. In summary it must be accepted that the average risk from structural elements of hospitals is greater than the average risk of other structures within a city.
The natural vulnerability of hospitals towards disasters does not only arise from structural elements. Non-structural elements also cause a considerable amount of risk in disasters. Hospitals are filled with equipment that is potentially harmful especially in a disaster setting. There are some heavy objects which are sometimes not securely attached to the ground (e.g. mobile radiology equipment) that can cause considerable harm in case of an earthquake. The weight of many equipment can cause an unstable floor to collapse (this is one of the reasons why it has been recommended to place heavy equipment in ground floor or basements). Overall non-structural elements will usually be a source of risk following disasters or may hinder the response efforts.
The most important factor in hospitals vulnerability towards disaster is the nature of their functions. Hospitals are a place where patients (who are usually too sick to be treated as an outpatient) are hospitalized in order to receive medical care; this would mean that their clinical conditions are usually serious or critical. Patients are one of the most vulnerable groups in the
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society (among elderly and children) and most lack the capacity to react accordingly to disaster situations. Furthermore, most patients need constant care, so that even if the disaster itself does not cause them harm, disruption of services can potentially cause them harm.
Consequently, the ultimate goal of disaster management in hospitals is defined as continuity of care. The hospital not only needs to manage the effects of a disaster on structural, nonstructural and functional elements but it should also make sure that the wellbeing of the patients who are present at the hospital or will be admitted in the hospital following a disaster is not threatened by the disaster, as such continuity of care in essence is a continuation of protecting lives. Continuity of care as we mentioned before is not necessarily the same as provision of services, there are times that continuity of care is only achieved by rapid and effective transport of patients to nearby facilities; the hospital needs to ensure that its patients receive the care that they need irrespective of conditions. If continuity of care can be achieved by service delivery within the hospital without threatening the lives of patients or staff or causing serious damage to investment, then the best option is to provide care within the hospital, otherwise there is the option of transferring patients and providing care in an alternative facility whether it is another hospital or a temporary solution such as a field hospital.
Management of Internal Disasters with the Comprehensive Hospital Risk Management System (CHRMS):
Protecting lives, as mentioned before, is the number one priority in the CHRMS. Thus in planning stages, risks and hazards should be considered that pose the greatest risk towards lives. Protection of lives in this system occurs in three stages; the first is risk reduction stage, where vulnerability reduction or hazard prevention can considerably decrease the overall risk, yet this stage needs both considerable time and investment; it is a long term process of investments which will reduce the risk of the hospital in future. The second stage is preparedness, in preparedness the hospital needs to develop hospital disaster plans, train the staff and through regular exercises and drills maintain a high level of preparedness, in other words at this stage the hospital needs to build a capacity for responding to a disaster that may strike at any moment. This capacity is then used in the third stage, which is the response phase; the hospital disaster response plans along with the experience and knowledge of staff are crucial in determining the outcome of a disaster. Response is where the capacity of hospital is tested and if it fails the consequences will be devastating. The corner stone of a successful
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response is the hospital disaster response plan; in it the disaster and its effects have been anticipated and the hospital response has been designed accordingly. It will provide guidance and direction in a time of chaos.
In this project we have focused on hospital disaster response plans; in the second part of this report we have provided generic disaster response plans for the most common internal disasters faced by hospitals in Iran, they will provide a framework based on which each hospital in the country can create its own disaster response plan.
In a hospital disaster response plan, there should be plans for the three categories of protection; there should be plans for protecting lives, protecting investments and finally protecting functionality. These should be achieved with actions based on structural, nonstructural and organizational elements of the hospital.
Protecting lives should follow a defined pattern. The first step in this pattern is identification of threats, i.e. we should know what kind of threat we are facing from the beginning of the response phase. This should be followed by understanding the attributes, characteristics, effects and scale of the threat, this step is known as threat evaluation. These two steps are crucial in guiding the following steps of the response phase. It must be mentioned that these two steps need to be performed rapidly and efficiently.
These two steps must be completed as rapidly as possibly; in emergency setting precision is traded with speed, however the managers must make sure the rapid assessment is still precise enough that they can base their decisions based upon it. The third step involves efforts aimed at neutralizing the threats. This minimizes the damage caused by a hazardous event yet in deciding whether to pursue threat neutralization or not, all factors should be considered, sometimes the disaster is far too widespread or far more serious for the hospital staff to neutralize and in such instances the precious time that can be allocated to saving lives may be wasted in a fruitless effort at neutralizing the disaster. The next step is threat containment; in this step the staff should try contain the threat within an area or limit the timespan of the threat. This in turn buys the staff precious time which will allow for implementing an effective response and eventually limiting the damage and negative effects of the disaster. For example in a fire, closing fire doors can effectively contain the fire to a limited area. The final step is
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evacuation which can be partial or complete. It must be mentioned that although this is the general outline of response to internal disasters, the order of steps can be changed in specific disaster settings or when the command team determines, for example there may be need for emergency evacuation of the hospital before any other steps are attempted.
To ensure continuity of services and protection of functionality, the first step will be to assess the possibility of continued service delivery within the hospital. If there is no immediate threat to lives or investment, the priority of service delivery is always to provide services within the hospital; because it has been specifically designed and built for clinical service delivery which makes the ideal setting for patient care. However if the hospital building is not available as a choice for service delivery or the patient load exceeds the post disaster capacity of hospital for service delivery, then care can be provided in temporary alternative settings; these must be covered spaces that are protected from the threat of elements. The patients are transported to these temporary sites and care is provided to them until a permanent solution can be found. Such sites should have been determined as part of the planning stage and the necessary equipment should be stored in them or near them for easy and quick access. These sites are not only important in internal disasters but they form an essential part of surge capacity plan as well. If the recovery of the hospital will be prolonged and nearby hospitals have the capacity to receive the patients from the disaster stricken hospital then relocation should be considered.
Capital or investment protection has two main aspects; one is protecting the non-structural elements. In some cases it may be possible to remove the non-structural elements from the immediate disaster area; this is especially true for light and portable equipment. If there is enough time and no immediate threat to lives is present then securing, removing and evacuating equipment can be attempted. Structural protection is not as effective as predisaster risk reduction however there are actions that can be performed by specialized and trained teams that can reduce or repair the structural damage following a disaster.
In the remainder of this chapter we will further explain the steps of internal disaster management in hospitals.
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2.1 Protecting Lives:
2.1.1 Identifying the threats:
The internal threats can be categorized as fast and slow disasters. In fast disasters, the disaster itself or its immediate effects are identified and elicit a response but in slow disasters, the occurrence of the disaster can be predicted using some criteria or a set of measures and the response can be planned and implemented accordingly. Immediately after identification of threats the hospital incident command system should be activated and the hospital disaster response plan implemented.
The fast disasters usually require a rapid reaction immediately after identification. This rapid reaction can help to temporarily delay or reduce the effects of the disaster and allow for a full scale and proportionate response to be launched later. For example in fire disasters, the rapid reaction consists of the RACE protocol and when this protocol is implemented the further steps indicated by the hospital disaster response plan can be implemented. The rapid reaction is a temporary measure and cannot be considered a full response and thus a delayed reaction which consists of the response procedures mentioned in the hospital disaster response plan should be started immediately after the rapid reaction. The delayed reaction is more precise and is based upon data provided by the threat evaluation phase.
In slow disaster, identifying predicting factors help to activate the appropriate response mechanisms. Ideally in slow disasters, the response system should nullify the factors causing the slow disaster and thus prevent it, however, if this is not possible the timeframe of slow disasters allows for better planning and preparedness which can improve the response phase.
Identifying threats has two main components; the first is the threat identification itself and the second component is warning and alerting. If the identification of a threat does not lead to an effective warning, then it cannot elicit a proper response either.
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Identifying threats is performed manually or automatically. For some threats, a series of detectors can be placed around the hospital; smoke detectors, thermal detectors and chemical detectors (that can identify corrosive gases or assess the pH) are examples of such detectors. All these detectors have a higher sensitivity than humans in identifying threats, however their specificity is somewhat lower and they may cause false alarms. Humans can actively participate in threat identification as well; the staff must be vigilant and well trained so that a competent surveillance system can be established in the hospital that actively seeks the signs of threats and reports them. This surveillance system needs to be equipped with effective communication means as well as manual alarm activation in addition to the automatic system.
The second component as mentioned before is alerting and warning. Warning systems themselves have two important components; the first is the technology and infrastructure used which should be easily available and cover almost all of the target population. The second component which is as important as the first component is the protocols used for warning and alerting; these protocols determine the type of warning, the message contained in the warning and required response, in fact they govern the system and act as the software for the alerting operations. These protocols are called the common alerting protocols; in hospitals the common alerting protocols are also known as the emergency codes with each code being assigned a different color.
Many technologies are used in alerting systems, from many centuries ago, one of the main uses of communication technologies has been for alerting and warning. I hospitals the most readily available hardware for alerting is the hospitals public announcement system; this system is installed in almost all hospitals and thus it can be adopted as a warning system without much investment. It must be ensured, however, that the system provides complete coverage of all of the hospital and is not easily affected by disasters. One of the major problems with this system is that it is dependent on human interaction, and if the operator is not familiar with the hospitals coding system, they can be a source of confusion and may not be effective in alerting and warning. Thus experience has shown that if the public announcement system is used as an alerting and warning system then there must be some backup and axillary systems that can substitute it if the need arises. One of these is the automatic warning system which can automatically receive the information from detectors and after confirmation by an operator, activate the alerting and warning system. This system omits the need for a user with extensive knowledge of the coding system and anyone can activate in cases of emergency.
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One of the tools used in warning systems in hospitals is the automatic alarm system. This system is low cost, has high coverage and can induce a sense of emergency in all who can hear the alarm. This system however has a major flaw and that is the fact that it can not convey any information other than presence of an emergency. So alarms alone can not lead to the proper response and can not guide the response process. Evidence has shown that alarms without being supplemented by a complementary tool can cause panic and so it has been recommended that alarms alone should only be used in instances such as emergency evacuation. Alarm systems, however, can be effectively combined with other systems and tools. For example electronic boards can be placed around the hospital, these boards can display the color code of the emergency, and coupled with alarms these boards can be effective in initiating the proper response.
In hospitals that are equipped with a paging system, if the system has high coverage (at least three staff members in every ward or section should have a pager), then this system can be used effectively for warning and alerting as well.
It is worth mentioning that in hospitals, the target population for alerting and warning are the hospital staff. They should, according to the hospital disaster plan, activate the response plan and inform the patients and their relatives and guide them throughout the response phase. Patients and relatives, due to their lack of knowledge of the hospital disaster response plan, can show inappropriate reaction to a warning which may further complicate the situation. For example, if there is a fire in a room or a ward of the hospital and the fire alarms are activated throughout the hospital, in the ensuing panic, the patients and their relatives, even if they are not in endangered zone may rush to exits and cause harm to themselves and others. Thus it is better that warning and alerting in areas outside the immediate danger zone, be provided by the staff along appropriate additional information that can help to calm the patients and their relatives and prevent a chaos.
The activation of the internal response plan is not the only objective of the alerting and warning system and it must be ensured that the external response teams are also alerted. For example, in case of a fire, the fire stations should be alerted as well. Consequently, all external response teams should be alerted, preferably by an automatic system, when an emergency occurs. In the same example of a fire in the hospital, the smoke detectors should be connected to the fire station as well. If there are no automatic systems, then a common protocol should be agreed
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between the external response teams and the hospital and a person who is aware of that protocol should be present at the hospital at all times.
In alerting system, messages are usually of five different categories. The first is the alert type, which contains basic information on the event that has occurred. The second is the additional information message and the third type is the cancel message which nullifies a previous message. The fourth type is called receipt message which confirms the receipt of the alert and is conveyed from the end users to the operator and finally the fifth type is called the error message which shows that either a previous message has not been received or shows an objection to the contents of that message. Each alert message has 4 types as well. First are the Real alerts that show that a threat and emergency has occurred. These alerts should be followed by either Confirm or Cancel messages. The second are the Practice alerts that simulate a virtual emergency and are used for practicing the codes by the operator and receivers. The third type are the test alerts that are used for checking the system and do not require a response and finally the fourth type are the system messages which are internal, technical, maintenance messages. For example, after announcement of Alert, Red Code, Infectious Disease Ward, this must be followed by Confirmed, Red Code, Infectious Disease Ward so that staff can assured that the warning is real. It is suggested that the codes are practiced and announced on a daily basis (practice alerts) so that every staff member is familiar with codes.
2.1.1.2 Common Disaster Codes:
Common disaster codes are a set of coloured codes that are used for alerting and warning in emergency setting. These are a form of common alerting protocols that are announced by electronic boards or the public announce systems. These codes ensure that everyone has the same perception of the event and allow for timely and accurate warning. These codes have the additional advantage of not causing panic in the patients and most importantly these codes are response based and each code elicits a predefined series of actions (as determined by the hospital disaster plan).
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Coloured codes represent the hospital disaster response plans. Planners should devise the plans according the defined codes. In other words the final plan for each threat or emergency should be easily found according to the color code of that threat or emergency. For example, the final plan can be printed on coloured pages or at least the color of the cover of the section of the plan that is allocated to that specific threat should be the same as the color code assigned to that threat.
It must be mentioned that color coding is not used to hide the necessary information but it is used to convey additional and useful information. For example in case of a fire, the alarms in the affected section will be activated but the announcement of red code will let the staff know about the nature of the threat and the response that is required of them.
Preferably the common codes should be the same in all hospitals in an area. This is helpful when staff from nearby hospitals come to the disaster stricken hospital for providing assistance. In the first table we have shown the common color codes that are used for disaster codes. This table is merely a suggestion and hospitals can adopt it according to their own codes or plans.
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Table1 : Common Disaster Codes Event Code Justification
Fire
Code Red
Red is the color of fire, red is already used in many hospitals are the color code representating fire. Patients who develop cardiopulmonary arrest become cyanotic and bluish.
Cardiopulmonary Arrrest
Code Blue
Reception
Code Orange
Most serious patients arrive by ambulances, orange is the international color for ambulances.
Preventive Evacuation
Code Green - Green is always representative for exits and is a Delayed sign that a path is clear Code Green Emergent Code Yellow
Emergency Evacuation
Lost Patient
Bomb/Security Threat
Code Black
Black is the color of smoke
Chemical Threat
Code Brown
Many harmful chemicals have brownish color
External Air Exclusion
Code Grey
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2.1.2 Threat Evaluation:
Threat evaluation provides critical information on severity, extent and the nature of threat as well as its potential effects on the hospital. This information greatly facilitates the response and ensures that the response actions are appropriate and proportionate to the event.
Threat evaluation is performed in two stages; the first is rapid assessment and the second is the secondary comprehensive assessment of threats and damages. The first stage is considered as a part of the response phase while the second stage is usually performed after there are no immediate threats to lives and commonly at the end of the response phase. In fact the rapid assessment is necessary for enhancing and facilitating the response and the results of the secondary assessment are usually used for recovery phase.
The objective of rapid assessment is to determine the threats in three levels. Just as protection in hospitals is composed of life protection, investment protection and functionality protection, in rapid assessment too, threats to lives, investments and functionality should be evaluated. In rapid assessment and in internal disaster the first thing to determine is the need for immediate and emergency evacuation. In other words in the first step, using a predesigned checklist, it must be decided whether the hospital needs to be immediately evacuated or not. If it was determined that there is no need for immediate evacuation then the assessment and the rest of the response phase actions can be continued. Assessing the need for immediate evacuation should not take longer than 10 minutes and the whole process of rapid assessment should be over within the first 30 minutes after identification of a threat.
It must be mentioned that rapid assessment of threats should performed easily and rapidly. All the staff should be capable of performing this assessment and checklists should be prepared for rapid assessment and all the staff should be trained in using the checklists. The checklist should contain structural, non-structural and environmental factors. Close and precise inspection of structural elements, however, is a very specialized task and should be performed by the hospitals supervising engineer yet in the checklist for rapid assessment a simple and generalized tool should be provided for structural assessment which can be used by all the trained staff members. The success of rapid assessment is highly dependent upon the
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experience of the individuals performing it and thus through training and frequent exercises the capability of individuals for performing rapid assessment should be increased. We must emphasize that some of the aspects that are assessed should be guessed based on the experience and the knowledge of the individual. For example, in a fire emergency, the rate of the progression of the fire, or in a chemical spill, the amount of the spill are very important for making informed decisions for response (e.g. if the rate of progression of the fire is high, there may be need for evacuation of the whole hospital) and factors such as these are usually predicted based on both the information from the scene as well as a degree of guessing.
For effective rapid assessment, in each shift and preferably in each wing and floor of the hospital, an individual should be responsible for threat evaluation. This person should start the rapid assessment based on the prepared checklists as soon as a threat is identified and announced. He/she should finish the assessment within 30 minutes and report the results to the planning officer and the commander of the HEICS structure. This individual should refrain from participating in search and rescue efforts and should preferably be chosen from staff members that are not directly involved in providing medical care.
Rapid assessment in disasters that have a long time frame or are of a recurrent nature or threats that evolve with time should be performed on a routine and cyclic basis. For example following an earthquake, aftershocks are common and after each aftershock the rapid assessment should be repeated or in fire emergencies, if the fire is not extinguished by fire fighters, then assessment should be repeated each 30 to 60 minutes.
An important point is that even if a threat appears to be localized to a certain part of the hospital, in threat evaluation all of the hospital or at least the disaster area and its adjacent areas should be evaluated because sometimes the threat might have involved other areas without our knowledge and thorough inspection is needed in order to clearly determine the extent of the threat.
For rapid structural assessment the following categorization can be followed. It is worth mentioning that the main events that threat the hospitals structure are earthquakes, explosions, fires, landslides, hurricanes and floods.
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Table2 : Categories of Structural Damage for Rapid Assessment
Damage Level
Heavy
Description
Heavy Damage: Destruction of a part/ or an entire section or floor Movement or oscillation of the structure on its foundation Structural instability (Major cracks on main columns, destruction of weight bearing walls, columns or beams) Structural deviation or angulation
Examples
Suggested Actions
and
Disruption of horizontal lines: Immediate o Non parallel lines when emergency aligning windows evacuation o Non parallel lines when aligning floor and roof o Depression of the structure Disruption of vertical lines: o Structural deviation o Disrupted door frames and jammed doors Major cracks: o Major cracks in the main columns and walls Fragmentation of structural elements Liquefaction
Moderate
Moderate Damage:
Destruction of exterior and interior elements Presence of minor and hairline cracks on different structural elements No structural deviation and firm attachment to the foundation
Destruction of non-weight bearing and partition walls Detachment and falling of nonstructural elements Cracks and damage to paint and plaster and interior design elements Breaking of pipes and utility canals
Structural assessment by the supervising engineer as soon as possible Non-structural and functional assessment Initiate response protocols Non-structural and functional assessment Initiate response protocols
Light
Light Damage:
Broken Windows Cracks in the paint and plaster
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In heavy damage to the hospitals structure, the level of threats towards lives is very high and consequently the best option is emergency and immediate evacuation of the structure. In instances, however, that the external conditions are severe especially for the patients (e.g. very cold weather) if the supervising engineer determines that the hospital is temporary safe, the hospital can be used as a temporary shelter until an alternative is prepared. In moderate and mild damage to the structure, the chance of threats towards lives rising from the structure is limited and threats towards lives are mostly from non-structural and functional elements. In moderate and light damage, the threats towards investment and functionality caused by structural elements can be evaluated and ideally neutralized. A list of threats caused by the structural elements towards the investment and functionality should be made, a sample of such a list is provided below.
Table3 : Checklist for Structural Threats Assessment

Nature of The Structural Threat Place Threat towards the Functionality Threat towards the Investment Suggestions Responsible Official
Mild
Moder ate
High
Mild
Moder ate
High
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For a more accurate assessment of the structure, specialized tools and checklists can be used, however using them is time consuming and needs expertise. In cases when the results of rapid assessment are suspected or the results are not conclusive, an expert team can assess the structure using more advanced technics.
In the next step the non-structural and functional elements should be evaluated. In this evaluation, the following categorization (adopted from Guidelines for seismic vulnerability assessment of hospitals, WHO/NSET, 2004) can be used. This categorization is a compilation of structural, non-structural and operational elements. In this categorization the conditions where there is heavy structural damage (as determined by the previous category) is not mentioned, because in conditions where heavy structural damage is present, the hospital should be immediately evacuated and there is no further time for non-structural and operational assessment.
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Table 4: Levels of Damage (adopted from Guidelines for seismic vulnerability assessment of hospitals, WHOSEARO/NSET, 2004)
Performance Levels and Overall Damage Operational (Slight Damage)
Expected Levels of Damage to the Different Systems Critical Systems / Components Contents and Equipment of Medical Facilities Lifts operate; ducts and piping sustain negligible damage; the fire response system is functional; transformer / generators are functional and electricity can be provided; water can be provided. Medical equipment on floors and walls is secure and operable; power is available; equipment on rollers slides but does not tip and does not impact with anything; cupboards, racks cabinets and book shelves do not tip; negligible damage to chemical bottles in the lab; oxygen cylinders and blood stands are not tipped over. Medical equipment on floors and walls is secure but power may not be available; some equipment on rollers slides and impacts with something; cupboards, racks cabinets and book shelves do not tip; negligible damage to chemical bottles in the lab; blood stands may tip.
Architectural Elements Negligible damage to false ceilings, chimneys, light fixtures and stairs; minor damage to parapets and doors; minor cracks in cladding and partitions.
Immediate Occupancy (Slight to Moderate Damage)
Life Safety (Moderate to Heavy Damage)
All system components are secured; generators start but may not be adequate to service all power requirements; minor leaks in some joints of water supply pipelines; fire systems and emergency lighting systems are functional; medical gas supply systems are secure and functional if electricity is available, lifts are operable and can be started when power is available. Lifts out of service, some breakages to pipelines and ducts; some fixtures broken; electrical distribution equipment shifts and may be out of service; breakages in medical supply systems near heavy equipment. Some critical systems equipment slides or overturns; some piping lines rupture; generators will be out of function; some damage to the fire response system.
Minor damage to ceilings, chimneys, light fixtures, doors; some window glasses crack; some cracks to partition walls.
Hazards Reduced Levels (Heavy to Very Heavy Damage)
Medical equipment shifts and disconnects from cables but does not overturn; most equipment on rollers slides; some cupboards, racks cabinets and book shelves tip; some damage to chemical bottles in the lab; lab equipment slides from tables. Equipment rolls, overturns, slides, and cables are disconnected; some equipment requires reconnection and realignment; sensitive equipment may not be functional; cupboards, cabinets and racks overturn and spill contents; severe damage to lab chemicals.
Extensive cracked glass, some broken glass; severe cracks in partitions and parapets; doors jammed; some fracturing to cladding.
Generally shattered glass and distorted frames; widespread falling hazard; damage to partitions and parapets; severe damage to claddings; extensive damage to light fixtures.
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For evaluating non-structural elements in each ward or floor of the hospital a complete list of non-structural elements based on the following format must be prepared. The assessors should be trained in using these lists and these lists should be included in the disaster response plan of each ward or floor.
Table5 : Checklist for Non-Structural Threat Assessment

Nature of The NonStructural Threat Place Threat towards the Lives Threat towards the Functionality Threat towards the Investment Suggestions
Responsible Official
Mild
Moder ate
High
Mild
Moder ate
High
Mild
Moder ate
High
Air Conditioning False Roof Heating Cabinets Cupboards Partitions Lights and Electrical installations Internal Design elements Utilities Canals Chimneys Windows Doors &
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A list should also be prepared for the functional and operational elements of each hospital and it should be readily accessible in hospital disaster response plan. A sample of such a list is provided below.
Table6 : Checklist for Functional Threat Assessment

Nature of The Functional Threat Place Threat towards the Lives Threat towards the Functionality Threat towards the Investment Suggestions
Responsible Official
Mild
Moder ate
High
Mild
Moder ate
High
Mild
Moder ate
High
Electric System and Generators Water System and Pipes Fire Sprinklers and Fire suppression systems Communication Systems Important Clinical Services Imaging Radiology Laboratory Blood Bank Clinics ICU OR and
ER
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Threat evaluation will show whether neutralization or containment of the threats is possible or not. If threat evaluation shows that neutralizing or containing the threats is not possible and the threats have a progressive nature which may harm occupants and patients in the near future, even though no immediate threats to lives are present at that moment, the decision makers should consider preventive evacuation of the hospital.
Threats against investment come in two main categories; one is the threats towards the structure and the other is the threat towards the non-structural elements of the hospital. These threats should be identified and assessed in threat evaluation; for structural threats, the supervising engineer should lead the assessment team and for non-structural threats which also include the utilities and installations, the installation and maintenance engineers should conduct a complete survey. We must reiterate that conducting this evaluation should be postponed until no immediate threats to lives are present. For example, when there is a need for the electricity created by the generators in the hospital, the maintenance crew should not turn off the generators for inspections.
Threats against function act by affecting structural, non-structural or operational elements of the hospital. In evaluating threats towards functionality, vital installations and utilities (electricity, water, medical gases, lifts, ) as well as the important wards and sections of the hospital (ICU, ER, OR, ) should be inspected and threats towards their functionality should identified and assessed. If there are no immediate threats or the threats can be neutralized, then service delivery inside hospital would be possible. If service delivery within the hospital is not possible but there hospitals nearby with enough capacity to receive the patients from the disaster stricken hospital, then priority should be given to relocating the patients but if there are no hospital nearby that can accept the patient, then a temporary hospital should be set up. This temporary site should be set up according to the protocols of hospitals surge capacity plan.
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2.1.3 Threat Neutralization:
Neutralizing threats is highly dependent on the nature of the threat that the hospital is facing. In some disasters, threats cannot be neutralized at all, e.g. neutralizing an earthquake is not possible however the secondary threats that arise in its aftermath like fire, obstruction of corridors, etc. can be neutralized. Threat neutralization is usually a highly specialized task and without enough technical expertise and equipment it should not be attempted. For example, in a fire emergency, the suppression and extinguishing of the fire should be performed by firefighters. In the hospitals disaster response plan it should be indicated that for which disaster and threats and under which circumstances the staff may attempt to neutralize the threats. In cases where threat neutralization is allowed, the staff should be adequately trained and the necessary equipment should be provided. For example in chemical spills, attempts at threat neutralization and decontamination can be made, this however requires that full protective gear be available and some members of the staff should have received HAZMAT training.
Overall, in threat neutralizing we suggest that instead of attempting to neutralize the main threat or hazard, it is better to try and counter the effects of the hazard. i.e. the effects of the original hazard that are threating lives, investment or functional should be identified and neutralized if possible. For example, if the primary hazard (e.g. a fire emergency) has threatened the life of a patient (e.g. the patient has suffered burns) then the patient should be taken away from the threat zone and provided with medical care, while the original hazard has not been neutralized its threats towards the lives of the patients have been neutralized. This is due to the fact that contrary to the other phases of disaster management where the emphasis is upon prevention and addressing the roots of a problem, in response phase the priority is to counter the effects and damages caused by a threat or hazard. This can be likened to symptomatic treatment in medicine, where priority is given to stabilizing the patients vital statistics rather than the cause of his/her condition.
Threat neutralization is better left to experts, but still threat neutralization is an important step in hospital disaster response and if it can be managed, it can greatly improve the prognosis of a threat/hazard and reduce the amount of investment needed for the hospital to make a full recovery.
July 2011
2.1.4 Threat Containment:
Unlike threat neutralization, threat containment is a simple task that should be considered in all disasters. The objective of threat containment is to limit the progression of the disaster. Such containment can be applied to the chronology of the threat. This creates a delay in progression of the threat that allows for specialized response teams to reach the hospital and participate in threat neutralization. The span of the disaster area can also be contained; this is highly effective in limiting the damage and is a very important task in protecting lives, investment and function.
Containing the span of a threat is managed by using structural elements. Hospitals are designed in modules, wings and separate areas and wards; the different sections of the hospital are usually separated by a physical boundary and are structurally separated (using walls, doors, windows ). Such boundaries help to contain the threats within a confined space with minimum effort; this can be achieved by closing doors, windows and blocking corridors. The hospital designs allow for complete isolation of a ward or section even air movement can be restricted which is very useful in containing epidemics, chemical spills and radiologic events. Sometimes containment requires extensive human intervention, for example the threat of collapse can be contained by using temporary measures such as shores or cribbing, this allows for enough time to evacuate the building as well as time for essential repairs to be performed.
Chronological containment depends on the installations of the hospital. For example a fire suppression system may not be able to extinguish an extensive fire but it can greatly reduce its rate of progress and allow the firefighters to effectively extinguish the fire. Aspects of other installations are very important as well, for example automatic shutdown of medical gases, automatic fire doors, powerful ventilator in potentially hazardous settings and etc.
One of the most important aspects of containment is establishing a quarantine and isolation system. Quarantine and isolation help to contain the harmful agent to be confined to few individuals and a closed space. In dealing with contagious diseases, quarantine and isolation can stop the incidence pattern or even reverse it. Especially in instances where a dangerous pathogen is found within a hospital, isolation and quarantine can protect the staff and patients from contacting the disease and ideally allow for eradication of that strain of the pathogen. In
July 2011
chemical and radiologic events as well, isolation helps to contain the spread of the agents in the hospital and allow specialized HAZMAT teams to intervene. The most important aspect of isolation and quarantine protocols is to establish a danger zone and a safe zone so that the chance of contracting the offending agent outside the danger zone is minimized. These two zones should be separated and only be connected with a single (or in some cases more than one) passage; is this passage decontamination and disinfection should be performed.
2.1.5 Evacuation:
Evacuation is one of the most critical decisions that hospital incident commanders face. If there is a need for evacuation, early implementation of evacuation protocols can potentially save many lives. On the other hand unnecessary evacuation is a hazard itself; not only patients will be deprived of clinical services but they will also be at the mercy of elements. So as stated earlier, it is prudent that the incident commander is able to decide about the need for immediate evacuation early on using the data from the rapid assessment survey. Each hospital should design simple evacuation criteria that can facilitate the ICs decision for evacuation. The evacuation procedure should be predefined for each ward, floor, wing as well as the procedure for complete evacuation.
In evacuation a very important concept is mobility management. Evacuation should be organized; otherwise it can become chaotic and endanger the lives of patients and staff. In mobility management the paths, capacity of each path, exits and destination should be determined and staff should be trained in conducting and guiding the evacuation process. For example, if all evacuees are directed to the same exit, a bottle neck effect will be created which can lead to serious harm. In the hospital disaster plan, each section, floor and ward should have an evacuation plan and in each section it must be defined that who has the authority for overseeing evacuation in each shift.
Another important aspect of evacuation is re-entry. Before hospital can be occupied again, a full inspection of the hospital is necessary. Re-entry should only be allowed if the safety of the hospital is assured.
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2.2 Continuity of Service Delivery:
After the critical phase of S&R and relief is finished, protection of lives continues with providing clinical services to patients and injured. Continuity of service delivery is conducted in three levels.
The first level is service provision within the hospitals structure. If the structural safety is established the priority is to continue providing services as before. If some of the clinical areas of the hospital are non-functional or if the patient and casualty load surpasses the existing capacity of the hospital then non-clinical spaces within the hospitals structure (corridors, conference rooms) can be transformed and used as clinical spaces, this transformation is performed based on the surge capacity protocols. We will discuss surge capacity protocols in detail in the third report.
If service delivery within the hospital building is not feasible or if the patient load far surpasses the buildings capacity then a temporary medical site can be set up in closed space near the hospital. In surge capacity plan such a place should have been identified and the necessary equipment and supplies should have been stored nearby. In chronic disasters or in cases where the nearby hospitals have the capacity to provide patients from the disaster stricken hospital, patients can be relocated.
Resource management is very important in continuation of service delivery. The hospital, on one hand, has lost a part of its resources due to the disaster and on the other hand, it faces an increased load of patients and injured because of the disaster. Thus the resources of the hospital will be strained and this can lead to serious interruption of service delivery. Each hospital should have a plan for resource management in crisis situations. An important part of resource management is human resource management. In continuation of service delivery, the hospital may need more staff and by activating surge capacity protocols (including the call back protocol), the hospital can meet the extra demand.
July 2011
2.3 Protecting the Investment:
If there are no immediate threats to lives of the occupants of the hospital, efforts can be aimed at investment protection (structural and non-structural). Protecting the structure (including the buildings and the installations) is assigned to the supervising engineer as well as the maintenance and installation engineers. These individuals with help from expert crew can assess the hospital (after their safety is ensured) and start the necessary repairs. Their actions should be coordinated with the IC. In the response phase their main mission is to undertake temporary measures that can prevent further harm and damage to the structural elements until a permanent solution can be applied in the recovery phase.
Non-structural elements including medical equipment are an important part of the investment. In critical situation and when no lives are at danger, the mobile equipment can be evacuated from the immediate disaster zone. If the equipment is fixed or evacuation is not possible, after ensuring safety, maintenance and repair teams should assess the damage and perform the necessary repair.
In protecting investment, insurance is very important. Preferably all the hospitals capital (from structural to non-structural) should be insured against disasters and crisis situations. If the hospital is insured, before any attempt at repair and rebuilding, the representative of the insurance company should be contacted and repairs should start only after the insurance representative has inspected the damage and confirmed the repairs.
July 2011
3.1 General principles of internal disaster management:
Irrespective of the type of the internal disaster that the hospital faces, some principles should be adhered to in the response phase. These are part of the comprehensive hospital risk management system. Without implementing these principles the before mentioned approach to internal disaster will not be successful. We have introduced these principles below.
3.1.1 Adherence to the framework set by the CHRMS:
The hospital disaster plan and especially the hospital disaster response plan are parts of the CHRMS. Following the guidelines of CHRMS and adherence to the overall 5 steps approach, is critical in the success of the response phase. All of the hospitals staff should be trained in CHRMS.
3.1.2 Activating the HEICS:
HEICS is central component of a successful hospital response, it is a decision system applied to disaster within a hospital. In HEICS the hospital manager is not necessarily the incident commander (IC). IC is the person who is present at the time of the disaster in the hospital, has extensive knowledge on the hospital and its make up as well extensive knowledge on emergency management and the hospitals CHRMS. In HEICS the tasks are delegated to individuals and this delegation facilitates the implementation of the response plan. In this system, the IC and the operations officer lead the implementation procedures, while the planning officer supervises the evaluation and helps with transformation of the hospital response plan into an action plan. Others like the liaison officer, communication officer, financial officer and act as the supporting structures for the system and its operations. This decentralization of the decision making process, improves the systems capacity for information
July 2011
flow which is the corner stone of success in disaster setting. Furthermore, HEICS follows the standard structure of the incident command system and thus members and teams from other facilities or response organization will be familiar with it, this will facilitate coordination and cooperation and enhance the work of the response teams.
3.1.3 Activation of the response plan:
In disasters, 80% of the response actions are generic i.e. they will follow the same principles irrespective of place, time and type of the disaster. 15% of the response actions are dependent on type, place and time of the event and finally only 5% of the actions are based on the specific event. This means if a proper response plan is designed and practiced in the hospital, almost all crisis situations can be dealt with using that response plan. Consequently, in all disasters the first step after identification of the disaster is activation of the response plan, in other words, the response plan should transform from a paper plan into an action plan. This plan, however, will be a general guide and some tasks may be reconsidered based on the facts of the field; adoption and changing the plan is the task of the planning officer of the HEICS. Response plan activation along with HEICS ensure that the response is organized and controlled.
3.1.4 Communication:
Successful disaster management needs effective information flow. Thus even in the hardest and most devastating disasters, it is prudent that hospitals maintain a capacity for internal and external communication. In order to achieve this, the hospital in addition to its normal communication systems needs emergency communication systems whose infrastructure is resilient towards disasters (For example short range radio transmitters). In other words, in hospital communication systems the principle of multiple redundancies should be followed, so if a communication system fails, an alternative can be utilized.
July 2011
3.1.5 Resource Management:
Resource management forms the backbone of service continuity and protection of functionality in an internal hospital disaster. The hospital, on one hand, has lost a part of its resources due to the disaster and on the other hand, it faces an increased load of patients and injured because of the disaster. Successful resource management relies on redundancy systems and supply management. The stocks of the hospital should be planned in a way that allow for rapid replenishing of necessary supplies in a disaster event. Resource diversion and generation are also very important aspects of resource management. We will further elaborate the principles of resource management in the third report of the project.
3.1.6 External Coordination:
The external teams that participate in hospital response usually do not know the hospital layout or the hospital response plan and uncoordinated participation of them in the response phase can lead to chaos and further complication of the situation. As a result the liaison officer of the HEICS should coordinate with their liaison officers and their deployment should only be allowed within the framework of CHRMS and under the oversight of the IC, operations officer and the liaison officer. It is recommended that in all instances an individual from the hospitals liaison team accompany the external team in order to inform them about the hospital layout and plans.
3.1.7 Public information and managing the concerned relatives:
After a disaster event, the hospital faces the inevitable rush of relatives of the patients and staff. In order to calm them and also inhibit them from participating in actions that can harm
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themselves or the hospital occupants, the hospital needs to have had a plan beforehand. In this plan a waiting area should be assigned to them where they can be constantly informed on the situation inside the hospital. An emergency information center preferably with a hotline should also be established.
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4 References:
1. Sternberg E, Planning for resiliencein hospital internal disaster. Prehosp Disast Med 2003;18(4):291-293 2. Milsten A: Hospital responses to acute-onset disasters: A review. Prehosp Disast Med 2000;15(1): 3245. 3. Landesman, L.Y. Emergency Preparedness in Health Care Organizations. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 1996. 4. Disaster Planning in Health Facilities, James Hanna 1994, Oxford University Press 5. Milsten A., Hospital responses to acute-onset disasters: a review. Prehosp Disaster Med. 2000 Jan-Mar;15(1):32-45. 6. Nates JL., Combined external and internal hospital disaster: impact and response in a Houston trauma center intensive care unit. Crit Care Med. 2004 Mar;32(3):686-90. PMID: 15090948 7. Aghababian R, Lewis CP, Gans L, Curley FJ., Disasters within hospitals. Ann Emerg Med. 1994 Apr;23(4):771-7. PMID: 8161046 8. Kim DH, Proctor PW, Amos LK., Disaster management and the emergency department: a framework for planning. Nurs Clin North Am. 2002 Mar;37(1):171-88, ix. PMID: 11818271 9. Kai T, Ukai T, Ohta M, Pretto E., Hospital disaster preparedness in Osaka, Japan. Prehosp Disaster Med. 1994 Jan-Mar;9(1):29-34. PMID: 10155485 10. Guidelines for seismic vulnerability assessment of hospitals, WHO-SEARO/NSET, 2004 11. Niska RW, Burt CW., Emergency response planning in hospitals, United States: 2003-2004. Adv Data. 2007 Aug 20;(391):1-13. 12. Emergency preparedness for hospitals. An overview. Health Devices. 2001 Sep-Oct;30(910):365-9. PMID: 11696970 13. Londorf D., Hospital application of the incident management system. Prehosp Disaster Med. 1995 Jul-Sep;10(3):184-8. PMID: 10155428 14. Gollnick D., Alerting of Population in Crisis, Public Safety User Requirements & Technology Solutions, France 2004 15. Effective Public Warnings and the Common Alerting Protocol, 13th World Conference on Disaster Management, Toronto 2003 16. Moore L., Emergency Communications: The Emergency Alert System (EAS) and All-Hazard Warnings, CRS 2005

Emergency Hospital Service Delivery - JPRM 2011 - Second Deliverable - English

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Hospitals Internal Disaster Response Plan

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

APW for developing SOP for hospital emergency service delivery

Amir Momeni MD. EHMTP Director Principal Investigator

Elham Yousefi MD. Technical Officer

WHO/EMRO, July 2011

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Amir Momeni MD, Project Manager June 2011

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

1.1 Hospitals and Internal Disasters:

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

1.2 Vulnerability of Hospitals:

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

2.1 Protecting Lives:

2.1.1 Identifying the threats:

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

2.1.1.2 Common Disaster Codes:

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Table1 : Common Disaster Codes Event Code Justification

Black is the color of smoke

Many harmful chemicals have brownish color

External Air Exclusion

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

2.1.2 Threat Evaluation:

Hospital Internal Disaster Response Plan

Momeni A., Yousefi E.

Hospital Internal Disaster Response Plan